Recommendations Tracker

We recommend that Coventry Health and Life Insurance Company refund to the Federal Government the $6,995,522 of estimated net overpayments.

We recommend that Coventry Health and Life Insurance Company continue to examine its existing compliance procedures to identify areas where improvements can be made to ensure that diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS's risk adjustment program) and take the necessary steps to enhance those procedures.

We recommend that the Program Support Center implement a control environment that includes fraud mitigation, in accordance with GAO's A Framework for Managing Fraud Risks in Federal Programs.

We recommend that the Program Support Center implement automated verification processes for bank account information changes.

We recommend that the Program Support Center conduct information system level risk assessments that include integration of fraud risk in accordance with NIST guidance for all PSC financial management systems.

We recommend that the Indian Health Service consider additional project prioritization procedures to fund the highest priority SFC projects based on readiness.

We recommend that the Indian Health Service validate the eligibility of homes and users by regularly reviewing and updating the HITS data.

We recommend that Indian Health Service develop formal guidance for the proration of Tier 1 design costs and Tier 2 and 3 planning costs between eligible and ineligible homes or users.

FDA should increase the number of facilities inspected each year and ensure that all facilities are inspected within the required timeframes.

FDA should assess reasons for the decrease in number of facilities inspected by FDA with significant violations and take action as appropriate.

CMS should inform States of nursing homes that appear from PBJ data to violate the required number of daily RN staffing hours.

Refund the Federal grant for the unsupported costs, excess purchases, and improperly claimed indirect costs.

Update its periodic supervisory review policies to reflect current operations and develop a process to ensure that its policies and procedures manual is current.

Work with the Department of Health Care Services to improve the Unit's access to and the quality of Medicaid claims data.

Implement policies and procedures to ensure effective fiscal control of its funds, property, and other assets.

We recommend that the Centers for Medicare & Medicaid Services update Medicare requirements for billing E&M services provided on the same day as intravitreal injections to help providers understand the appropriate use of modifier 25 (e.g., clarify the definition of a "significant and separately identifiable" E&M service and identify the circumstances that allow for an E&M service to be billed on the same date of service as an intravitreal injection).

We recommend that the Centers for Medicare & Medicaid Services provide more education to providers on billing E&M services provided on the same day as intravitreal injections and the appropriate use of modifier 25 to help prevent improper payments for those services. For example, CMS could: (1) emphasize that the decision to perform an intravitreal injection is part of the minor surgical procedure and a separate E&M service should not be billed for that work; (2) provide a clear definition of a "significant and separately identifiable" E&M service that is "above and beyond" the usual care associated with an intravitreal injection; and (3) provide examples of E&M services that would be considered significant and separately identifiable and above and beyond the usual care associated with an intravitreal injection.

We recommend that the Minnesota Department of Human Services work with the childcare providers to collect, as appropriate, overpayments of CCAP claims identified by our audit.

We recommend that the Minnesota Department of Human Services continue to take steps to automate childcare attendance records through real-time electronic reporting as recommended by the Minnesota Office of the Legislative Auditor.

We recommend that Maryland's Department of Health verify that providers correct the 253 instances of provider noncompliance identified in this report.

We recommend that Maryland's Department of Health collaborate with providers to enhance their facilities, staffing, and training.

CMS should obtain the Federal shares of MLR remittances from States that failed to return these amounts to CMS for the 2017-2018 and 2018-2019 MLR reporting years.

CMS should improve internal communication to confirm that States return the Federal shares of the MLR remittance amounts reported annually to CMS.

CMS should develop procedures to track (a) when each State is expected to return the required Federal shares of MLR remittances owed and (b) whether States have returned the Federal shares timely.

We recommend that ACL develop mitigating controls and strategies to address the high and moderate risks we identified.

We recommend that the Ohio Department of Medicaid ensure providers correct the 117 instances of provider noncompliance identified in this report.

We recommend that the Ohio Department of Medicaid work with providers to improve their facilities, staffing, and training.

We recommend that ACL develop mitigating controls and strategies to address the high and moderate risks we identified.

NIH should clarify for NIH-funded institutions which monetary donations they must report to NIH as other support.

We recommend that the Substance Abuse and Mental Health Services Administration work with the Contractor to strengthen procedures related to verifying facility information, such as validating a sample of facilities each year.

We recommend that the Substance Abuse and Mental Health Services Administration work with the Contractor to implement additional system edits in the Survey to prevent facilities from submitting the Survey without completing all of the critical information fields.

We recommend that the Centers for Medicare & Medicaid Services provide MACs with a thorough explanation of the QASP results.

We recommend that the Centers for Medicare & Medicaid Services offer MACs additional training and guidance, based on the results of their QASP, and include best practices used by MACs.

CMS should provide surveyors with instructions for how to assess the contents of nursing home emergency preparedness documentation as a part of the survey process.

We recommend that the Texas Department of Health and Human Services ensure that providers correct the 253 instances of provider noncompliance identified in this report.

We recommend that the Texas Department of Health and Human Services work with providers to improve their facilities, staffing, and training.

We recommend that the North Carolina Department of Health and Human Services, Division of Health Benefits develop mitigating controls and strategies to lower risk within the high- and moderate-rated risk areas we identified.

We recommend that the Centers for Disease Control and Prevention: Develop, implement, and maintain a centralized repository to store required documentation pertaining to PEPFAR funds that are redirected due to a pandemic or other emergency.